Can Chiropractic Care Be an
Important Solution for the Opioid Crisis?

NSAIDs v. Opioids
Chiropractic v. NSAIDs
Opioids v. Chiropractic

[NSAIDs = non-steroidal anti-inflammatory drugs]

Terminology
(1)

Opium is made from the poppy plant. [The opium poppy is the leading cash crop in Afghanistan].

Opiates are compounds that can be purified directly from opium without modification. This includes morphine and codeine.

Opioids are a synthetic form of opium, like oxycodone. OxyContin is pure oxycodone.

The dangers, addiction, and suffering attributed to the opium poppy have been recognized for 6000 years.

Opium was used by the ancient Greeks, including Hippocrates and Galen.

The ancient Romans also used opium. The Carthaginian general Hannibal used it to kill himself in 183 B.C.

Arab merchants brought opium to China in the seventh century A.D. After Chinese citizens began to smoke opium, 20-90% of the population became addicted to it, depending upon the region. Britain and China fought two Opium Wars between 1839 and 1860 (China tried to stop the British importation of the drug that was enslaving their country).

Americans consumed liquid opium, laudanum, including George Washington, Mary Todd Lincoln, and [the wife of lawman Wyatt Earp].

Diacetylmorphine was invented and distributed by the drug company Bayer around 1900. It was called heroin, for heroic. It was marketed as being safe for children and pregnant women.

Initially, opioid use was limited to patients with terminal cancer. Then a respected doctor from New York City, Russell Portenoy, MD, took the liberal use of narcotics one step farther, opening the door for doctors to prescribe long-term, high-dose narcotics. In 1986, Dr. Portenoy, a 31-year-old New York City pain specialist, published his paper in the journal Pain (2).

Dr. Portenoy believed it was time for American physicians to get over their fear of painkillers, what he called “opiophobia.”

Dr. Portenoy reported the stories of 38 people who were on high-dose pain medicines (12 were on OxyContin). Portenoy argued that three previously published studies had also shown that less than one percent of patients on chronic painkillers had become addicted to them.

When Dr. Portenoy launched a national campaign for opioid use, he based his claims on these 38 patients. His critics claim that “If you’re going to medicate a nation, at the very least you should base your recommendations on a mountain of evidence, not a molehill.”

Dr. Portenoy reasoned that, “opioid maintenance therapy can be safe.”

Charismatic, bright, and persuasive, Dr. Portenoy became the media’s “go-to” guy for pain management, frequently appearing in newspapers and popular magazines. His academic success was also meteoric; Dr. Portenoy wrote or co-wrote more than 140 papers in med¬ical and scientific journals and 15 book chapters. When Dr. Portenoy talked, doctors listened. Dr. Portenoy had now given doctors permission to come back to opium derivatives. This time, he assured them, there would be little addiction and death. Drugs like oxycodone had finally solved the problem of pain relief without addiction.

In late 1995, at the same time that Dr. Portenoy was urging American physicians to get over their fear of painkillers, the FDA approved Purdue Pharma’s timed-released version of OxyContin. Purdue’s sales force promoted the drug for the treatment of lower back pain, arthritis, trauma, fibromyalgia, dental procedures, broken bones, sports injuries, and pain resulting from surgery. In other words: everything.

In 2012, Russell Portenoy, who had become chairman of pain med¬icine and palliative care at Beth Israel Medical Center in New York City, recanted: “I gave innumerable lectures in the late 1980s and ‘90s about addiction that weren’t true,” he said.

During the previous decade, more than 100,000 people had died from overdoses of painkillers.

In the end, OxyContin was one of the most addictive narcotics ever sold. And Russell Portenoy’s war on pain was one of modern medicine’s biggest mistakes. (1)

When OxyContin (time-released oxycodone), first came onto the US market in 1996. It became one of the most addictive narcotics ever sold. (1)

Opioid overdoses were now the leading cause of accidental deaths in the United States.

Cause of Death

Opioids interfere with breathing in multiple, dangerous ways:

“Among the many rapid effects that opioids have on the body, one is particularly lethal: Breathing is restricted (3).”

Modern Problem

In September 2017, the US problem with opioids was quantified in the journal Annals of Internal Medicine in a study titled (4):

The objective of this study was to estimate the prevalence of prescription opioid use, misuse, and use disorders and motivations for misuse among U.S. adults. The survey used 51,200 adult subjects. The authors found:

• 91.8 million (37.8%) U.S. civilian, non-institutionalized adults used prescription opioids.
• 11.5 million adults misused opiate drugs (12.5%).
• “Among adults with prescription opioid use, 12.5% reported misuse.”
• 1.9 million US adults officially have an opiate use disorder.
• “More than one third of U.S. civilian, non-institutionalized adults reported prescription opioid use in 2015, with substantial numbers reporting misuse and use disorders.”

The authors note that the numbers they present are undoubtedly under representative of the opioid problem because they did not include an assessment of groups that are likely to take and to abuse these drugs, including:

• They did not survey homeless persons who were not living in shelters.
• They did not survey active-duty military personnel.
• They did not survey anyone in jail or other institutions.

In March 2018, the National Institute on Drug Abuse of the National Institute of Health (USA) notes (5):

• Every day, more than 115 people in the United States die after overdosing on opioids (about 42,000 yearly). [If chiropractic care was responsible for at most one patient death per year, the modern opioid epidemic in one year carries the same risk of death as 42 millennia of chiropractic care].
• The Centers for Disease Control and Prevention estimates that the total economic burden of prescription opioid misuse in the US is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.
• Yearly, about 2 million people in the US suffer from substance use disorders related to prescription opioid pain relievers, and about 600,000 suffer from a heroin use disorder.
• About 80 percent of people who use heroin first misused prescription opioids.

NSAIDs v. Opioids

Are opioid narcotic pain drugs more effective than non-steroidal anti-inflammatory drugs for the treatment of acute musculoskeletal pain? This question was addressed in a randomized clinical trial, November 2017, and published in the Journal of the American Medical Association (6).

The author’s objective was to assess if a combination of ibuprofen and acetaminophen (paracetamol) represented a viable non-opioid alternative for acute pain management. Their study included 416 patients with moderate to severe acute pain. The authors concluded:

“There were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics.”

This study would suggest that there is no good reason to administer opioid drugs for acute musculoskeletal pain over less dangerous NSAIDs. However, the adverseness of opioid drugs are primarily associated with their use for chronic pain syndromes.

It is stunning to know that the first study assessing the use of opioid drugs for chronic pain as compared to NSAIDs was published only this year (March 18, 2018). The study was published in the Journal of the American Medical Association, and titled (7):

Effect of Opioid vs Non-opioid Medications on Pain-Related Function
in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain:

The objective of this study was to compare opioid vs non-opioid drugs over 12 months on pain-related function, pain intensity, and adverse effects. This study was a Randomized Clinical Trial that involved 234 subjects. The non-opioid medication assessed was acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs).

Study subjects were recruited from the Veterans Affairs Health Care System, Minneapolis, Minnesota. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Chronic Pain was defined as pain nearly everyday for 6 months or more. The authors state:

“Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”

“Because of the risk for serious harm without sufficient evidence for benefits, current guidelines discourage opioid prescribing for chronic pain.”

The results and conclusions in this study include:

“Opioids caused significantly more medication-related adverse symptoms than non-opioid medications.”

“Studies have found that treatment with long-term opioid therapy is associated with poor pain outcomes, greater functional impairment, and lower return to work rates.”

“Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

This study was reviewed by the Back Letter in an article titled (8):

Landmark Trial Punctures the Myth That
Opioids Provide Powerful Relief of Chronic Pain

The Back Letter makes the following points:

“The deadly opioid overtreatment epidemic picked up steam in the late 1980s and early 1990s with the misguided notion that opioids are painkillers that can be used safely and effectively in the long-term treatment of chronic back pain—or other forms of non-cancer chronic pain.”

“The intervening years—and as many as 300,000 deaths in the related opioid overdose epidemic—have rebutted the idea that opioids can be used safely on a mass basis.”

“Opioids are perceived as strong pain relievers, but our data showed no benefits of opioid therapy over non-opioid medication therapy for pain.”

“The data do not support opioids’ reputation as ‘powerful painkillers’.”

“This is an impressive study.” “It is the first clinical trial comparing opioid and non-opioid medications with long-term follow-up. It provides strong evidence that opioids should not be the first line of treatment for chronic musculoskeletal pain.”

“Opioids are not achieving the benefits for which they are marketed. And everyone is now well aware of the adverse effects of opioids.”

Chiropractic v. NSAIDs

An Important randomized clinical trial comparing chiropractic spinal manipulation care to NSAIDs was published in the journal Spine, titled (9):

Chronic Spinal Pain:
A Randomized Clinical Trial Comparing Medication,
Acupuncture, and Spinal Manipulation

The subjects in this study suffered from chronic neck and back pain. They were randomly assigned to a nine-week trial of either prescription NSAIDs, needle acupuncture, or chiropractic spinal manipulation. Subject outcomes were assessed using standard measurement outcomes.

Although NSAIDs are not safe, they are safer than opioid drugs. The authors note:

“Adverse reactions to non-steroidal anti-inflammatory (NSAID) medication have been well documented.”

“Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.”

The study results and conclusions include:

“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”

“The consistency of the results provides evidence that in patients with chronic spinal pain, manipulation results in greater short-term improvement than acupuncture or medication.”

“Medication apparently did not achieve a marked improvement in chronic spinal pain and caused adverse reactions in 6.1% of the patients.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

This study was a nine-week clinical trial. Importantly, the authors reassessed the patient clinical status with a one-year follow-up (10). The findings from this long-term follow-up include:

“The present study assesses the extended follow-up (of at least 1-year) efficacy of medication, needle acupuncture, and spinal manipulation, as standardized and exclusive treatment regimens.”

“Spinal manipulation appeared to provide the highest satisfaction.”

“Patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.”

“In patients with chronic spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

Opioids v. Chiropractic

In 2007, a study was published in the journal Clinical Therapy titled (11):

Narcotic Drug Use Among Patients with
Lower Back Pain in Employer Health Plans:
A Retrospective Analysis of Risk Factors and Health Care Services

This study examined the employer health plans records of 165,569 employees to examine risk factors and health care services use consequences of narcotic drug use in patients with low back pain. The study sample included 13,760 patients with LBP due to mechanical causes. Nearly 60% were female and the average age was 47 years. Almost half of the patients with LBP (45%) used narcotic drugs. Pertaining to chiropractic, the authors noted:

“Patients with LBP who received chiropractic services were less likely to use narcotic drugs. Chiropractic care appears to be a substitute treatment to pain medication and other health care services in patients with LBP due to the different sequence of services for pain treatment.”

Earlier this year (2018), a study was published in The Journal of Alternative and Complementary Medicine, titled (12):

Association Between Utilization of Chiropractic Services
for Treatment of Low-Back Pain and Use of Prescription Opioids

The authors used a retrospective cohort design to analyze health insurance claims of 6,868 low back pain subjects from New Hampshire. In 2015, New Hampshire had the second-highest age adjusted rate of drug overdose deaths in the United States, a 31% increase from the previous year and more than double the national rate. The subjects were aged 18–99 years.

The authors note that there is an epidemic of opioid prescribing in the United States. They cite these facts:

• “More aggressive pain management efforts that began in the 1990s have led to an epidemic of prescriptions for opioid pain medications in the U.S.”
  
• “More than 650,000 opioid prescriptions are dispensed per day in the United States.”
  
• “One out of five patients with non-cancer pain or pain-related diagnoses is prescribed opioids in office-based settings.”
  
• “There is little evidence that opioids improve chronic pain, function, or quality of life.”
  
• “Long-term use of opioids is associated with overdose, misuse, abuse, and opioid use disorder.”
  
• “Among U.S. adults prescribed opioids, 59% reported having back pain.”
  

These authors note that opioid drugs are extremely addicting. Yet, little attention has been paid to the potential of non-pharmacologic pain treatment as a strategy for addressing the opioid epidemic. Specifically, chiropractic spinal manipulation is an effective treatment for chronic low-back pain. The results and conclusions of this study include:

“Among New Hampshire adults with office visits for non-cancer low-back pain, the adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of services provided by doctors of chiropractic compared with non-recipients.”

“Among patients with low-back pain, recipients of services delivered by doctors of chiropractic have a lower likelihood of using prescription opioids, compared with non-recipients.”

“Pain management services provided by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to lower costs and reduced risk of adverse effects.”   

Chiropractic care “could exert a positive impact on patients with low-back pain by reducing unnecessary care, lowering costs, and improving safety.”

“Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects.”

These authors considered the benefits of receiving chiropractic services for both reduced costs and reduction of opioid use to be “impressive.”

••••••••••

Gallup, Inc. is an American research-based, global performance-management consulting company. Gallup is best known for its public opinion polls that are conducted worldwide. Gallup provides research and strategic consulting to large organizations in many countries. Gallup has 30 offices in more than 20 countries, employing about 2,000 people.

In recent years, Gallup has been providing a report on the chiropractic profession. The most recent update was October 2017 (13). Some of the findings include:

• Americans prefer drug-free pain management over opioids
  
• 78 percent of Americans prefer to try other ways to address their physical pain before they take pain medication prescribed by a doctor.
  
• 63 percent of Americans agree most chiropractors have their patient’s best interest in mind
  
• Over half of adults in the U.S. (55%) say they are  likely to see a chiropractor if they had significant neck or back pain.
  
• Nearly 62 million adults in the U.S. saw a chiropractor in the last five years — with an estimated 35.5 million going in the last 12 months.
  
• Adults who saw a chiropractor in the last five years are generally very positive about their experience.
  
• Three out of four adults (77%) who saw a chiropractor in the last year describe the treatment they received during the last 12 months as “very effective.”
  

••••••••••

The evidence continues to mount that opioid drugs are dangerous, resulting in tens of thousands of American deaths yearly, and they do not result in better outcomes in patients suffering from either acute or chronic pain syndromes.

In contrast, chiropractic spinal manipulation is largely safe, effective, and provides long-lasting clinical benefit.

REFERENCES

1. Offit PA; Pandora’s Lab: Seven Stories of Science Gone Wrong; National Geographic; 2017.
2. Portenoy RK, Foley KM; Chronic use of opioid analgesics in non-malignant pain: report of 38 cases; Pain; May 1986; Vol. 25; No. 2; pp. 171-186.
3. Sanders L; Fatal Fix: Opioids Are a Potent Way to Shut Down Breathing; Science News; March 31, 2018; pp. 18-19.
4. Beth Han B, MD, PhD, MPH; Wilson M. Compton WM, MD, MPE; Carlos Blanco C, MD, PhD; Elizabeth Crane E, PhD, MPH; Jinhee Lee J, PharmD; Christopher M. Jones CM; Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health; Annals of Internal Medicine; September 2017; Vol. 167; No. 5; pp. 293-301.
5. The National Institute on Drug Abuse of the National Institute of Health; accessed May 9, 2018.
6. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J; Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial; Journal of the American Medical Association; November 7, 2017; Vol. 318; No. 17; pp. 1661-1667.
7. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S; Effect of Opioid vs Non-opioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial; Journal of the American Medical Association; March 6, 2018; Vol. 319; No. 9; pp. 872-882.
8. Back Letter; Landmark Trial Punctures the Myth That Opioids Provide Powerful Relief of Chronic Pain; Vol. 32; No. 7; July 2017.
9. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
10. Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005; Vol. 28; No. 1; pp. 3-11.
11. Rhee Y, Taitel MS, Walker DR, Lau DT; Narcotic drug use among patients with lower back pain in employer health plans: A retrospective analysis of risk factors and health care services; Clinical Therapy; 2007; Vol. 29; pp. 2603–2612.
12. Whedon JM, Toler AWJ, Goehl JM, Kazal LA; Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids; The Journal of Alternative and Complementary Medicine; February 22, 2018 [epub, ahead of print].
13. Gallup, Palmer College of Chiropractic. Gallup-Palmer College of Chiropractic Annual Report Americans’ Views of Prescription Pain Medication and Chiropractic Care. Washington, DC: Gallup. Inc., 2017.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”